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Total hip replacement

221 citationsUpdated Oct 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview¶

Total hip arthroplasty (THA) is a definitive surgical intervention for hip joint pathology, with indications spanning young patients under 21 years to those beyond the ninth decade of life [3, 173]. In adolescents, the procedure is reserved for carefully selected patients where alternative treatments are contraindicated or unacceptable [18]. For younger, active patients under 65 years, THA demonstrates excellent mid-term survivorship, with 10-year implant survival rates of approximately 94% regardless of surgical indication [47, 134]. While females often present with worse baseline conditions and show relatively less improvement at one year compared to males [35], THA remains a safe and viable treatment modality across diverse populations, including those with sickle cell hemoglobinopathies [44].

Surgical technique and implant selection are tailored to individual patient needs, anticipated longevity, bone quality, and surgeon experience, as no single design or system is appropriate for every patient [6]. The direct anterior approach is utilized by more than 25% of US surgeons and is associated with less pain and shorter hospital stays [2]. However, long-term data do not confirm implant longevity for specific approaches, and there is insufficient evidence to conclusively support that any specific minimally invasive technique provides faster recovery [167]. Bearing surface utilization has shifted significantly, with metal-on-metal bearings decreasing from 39.2% in 2007 to 5.5% in 2015, while ceramic-on-polyethylene bearings increased from 6.4% to 52.0% over the same period [2]. Cross-linked polyethylene (XLPE) now accounts for over 90% of acetabular liners in primary THA, supported by long-term data showing marked decreases in wear, osteolysis, and revision surgery beyond 15 years compared with conventional polyethylene [2].

Perioperative protocols have evolved to optimize outcomes and reduce complications. Tranexamic acid (TXA) is standard-of-care for reducing blood loss and transfusions, with no orthopaedic study demonstrating an increase in venous thromboembolic events [15]. Aspirin is endorsed by the American College of Chest Physicians for VTE prophylaxis due to lower risks of bleeding and incisional complications compared with alternative chemoprophylaxis [15]. Most patients are now discharged directly home, and rapid recovery protocols are utilized without increased perioperative complications [15]. Intraoperative periprosthetic femoral fractures occur in 0.1% to 5.4% of primary THA cases, while acetabular fractures occur in 0.2% to 0.4% depending on cemented or noncemented components [1].

Anatomy & Pathophysiology¶

Surgical Approaches and Anatomical Landmarks¶

The direct anterior approach to total hip arthroplasty utilizes the internervous interval between the femoral nerve and the superior gluteal nerve [5]. The anterolateral (Watson-Jones) approach traverses the internervous interval between the tensor fasciae latae and gluteus medius, both of which are supplied by the superior gluteal nerve [5]. In contrast, the posterolateral approach involves splitting the gluteus maximus and tenotomies of the short external rotators, with no internervous plane [49]. The lateral (Hardinge) approach involves splitting the gluteus medius and sometimes the vastus lateralis, also with no internervous plane [49].

Vascular and Neural Landmarks: The sciatic nerve travels closest to the acetabulum at the level of the ischium [184]. The peroneal nerve division is most often involved in sciatic nerve injury because this part of the nerve is closest to the acetabulum [184]. The ascending branch of the lateral femoral circumflex artery passes upward beneath the tensor fasciae latae and is encountered in the space between the tensor fasciae latae and sartorius during the direct anterior approach [184]. The transverse acetabular ligament extends between the two cotyloid pads at the inferior aspect of the acetabulum [184]. Errant retractor placement inferior to the transverse acetabular ligament can damage the obturator artery and vein [184]. The medial femoral circumflex artery is located underneath the quadratus femoris muscle or gluteus maximus tendon [184].

Femoral Morphology: The Dorr classification of proximal femoral morphology includes Type A ("champagne flute"), Type B, and Type C ("stovepipe") anatomy [49]. Type C femoral morphology is often seen in elderly females with osteoporosis and is often best treated with a cemented stem [49].

Biomechanics and Component Positioning¶

The primary function of the femoral component is the replacement of the femoral head and neck after resection of the arthritic or necrotic segment [231]. Restoration of the normal center of rotation of the femoral head is determined by vertical height, medial offset, and version of the taper [231]. Inadequate restoration of femoral offset shortens the moment arm of the abductor musculature and results in increased joint reaction force, limp, and bone impingement [231]. The normal femur has 10 to 15 degrees of anteversion of the femoral neck in relation to the coronal plane when the foot faces straight forward [231].

Gait and Offset: Hip offset differences greater or less than 5 mm do not significantly change gait patterns following total hip arthroplasty [185]. Surgical approach plays a greater role than hip offset reconstruction in producing more normal gait biomechanics following total hip arthroplasty [185]. Abnormal hip and knee joint loading during walking after total hip replacement has a biomechanical background originating from hip geometry reconstruction [119]. Combinations of gait and joint positioning parameters together explained up to 86% of the variation in hip force parameters after total hip replacement [127]. Degenerative hips experience more abnormal hip kinematics that leads to higher articulating surface forces and stresses within the acetabulum [149]. Restoration of normal hip biomechanics, specifically limb length equality and offset, is a key goal of total hip arthroplasty that favorably affects functional recovery [220]. A leg length inequality in the range of 1–20 mm does not impair the symmetry of time–distance parameters and hip kinematics and kinetics during gait and stairs walking [183]. Superior displacement of the hip center caused a 13% decrease in the moment arm of the abductors and a 43% decrease in their force-generating capacity [215].

Spinopelvic Kinematics: Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after total hip arthroplasty following improvement in hip flexion [200]. Kinematic pelvic changes highly impact cup anteversion in total hip arthroplasty [213]. Planning and measurement of the intended position of the acetabular component in the supine position may fail to predict clinically significant changes in its orientation during functional activities due to individual pelvic kinematics [232]. Disturbances in spinal and pelvic kinematics lead to abnormal hip function, which may contribute to complications following total hip arthroplasty [161]. The interplay between the hip and spine is dependent on spinal stiffness, pelvic tilt, and dynamic hip positions [206]. The lumbosacral and hip motions were the major contributors to global alignment postural change in total hip arthroplasty patients [227].

Pathophysiology of Complications¶

Osteolysis and Loosening: Periprosthetic osteolysis is a macrophage-initiated biologic response to submicron polyethylene wear debris [8]. Linear pattern osteolysis is associated with cemented and mechanically unstable components where debris accesses the implant bone interface through the effective joint space [8]. Focal pattern osteolysis involves expansile osteolytic lesions that develop by accessing through areas where implant fixation is incomplete [8]. Aseptic loosening results in progressive bone loss and periprosthetic osteolysis, accounting for 75.7% of all total hip arthroplasty revisions [383]. Susceptibility to aseptic loosening results from a combination of environmental and genetic factors [383].

Metallosis and Trunnionosis: Metallosis is defined as the accumulation and deposition of metallic particles secondary to abnormal wear from prosthetic implants that may be visualized as abnormal macroscopic staining of periprosthetic soft tissues [377]. Ions and particles shed from metal-on-metal implants can lead to local inflammation of surrounding tissue and less commonly, very rare systemic manifestations [377]. Fretting and crevice corrosion may occur in 2% or more femoral stem modular interfaces [8]. Diagnosis of trunnionosis is made based on serum cobalt level > 1 ppb and cobalt ions >>> chromium ions [8]. Trunnionosis should be considered as a potential cause of pain in symptomatic hips with increasing femoral head diameter (≥32 mm), cobalt-chromium heads coupled with titanium stems, flexible titanium stems, or cobalt-chromium modular necks [8]. Selection of a ceramic femoral head in primary total hip arthroplasty may reduce the risk for trunnionosis [8]. Adverse reaction to metal debris is associated with factors including acetabular implant malposition, reduced or excessive clearance, corrosion at modular junctions, smaller femoral head size (<46 mm) in hip resurfacing, and female sex [8]. The biologic reaction to metal wear products is T cell mediated and can result in synovitis, acute lymphocyte vasculitis–associated lesions, and pseudotumor formation [8].

Mechanical Noise and Head Size: Mechanical noise incidence in total hip arthroplasty ranges between 0.2% and 17.0% [8]. Audible noise associated with total hip arthroplasty has not been associated with implant failure or revision [8]. Increased femoral head size (>36 mm) has been associated with a clinical, substantial reduction in dislocation rates [8]. Increased femoral head size (>36 mm) has been associated with increased incidence of groin pain [8]. Increased femoral head size (>36 mm) has been associated with higher polyethylene wear rates among younger and more active patients [8]. Increased femoral head size (>36 mm) has been associated with corrosion and loosening of the head-neck junction [8]. There is no benefit in hip range of movement or hip function when head sizes > 36 mm are used [247].

Systemic and Comorbid Risk Factors: Sickle cell disease is associated with early prosthetic loosening due to extended bone infarct disease [184]. Sickle cell disease carries a higher risk of periprosthetic joint infection [184]. Psoriatic arthritis is associated with a higher periprosthetic infection rate [184]. Ankylosing spondylitis is associated with a higher risk for heterotopic ossification [184]. Hip hyperextension due to fixed pelvic deformity in ankylosing spondylitis can lead to a higher anterior dislocation rate [184]. Parkinson disease is associated with a higher dislocation rate, higher perioperative mortality, higher perioperative medical complications, and higher reoperation rate [184]. Paget disease is associated with increased blood loss during total hip arthroplasty [184]. Dialysis is associated with a higher risk of infection and loosening [184].

Nerve Injury and Hemostasis: Fat emboli syndrome occurs with femoral stem insertion when fat and bone marrow emboli are pressurized into the bloodstream [184]. Hallmark findings of fat emboli syndrome include intraoperative hypotension, hypoxia, mental status changes, and petechial rash [184]. Compression is the most common pathologic mechanism of nerve injury after total hip arthroplasty [184]. Of patients who have a nerve injury after primary total hip arthroplasty, only 35% to 40% will have recovery to normal strength [184]. The most common reason for sciatic nerve injury during surgery is errant retractor placement causing excess compression to the nerve [184]. Risk factors for nerve injury after total hip arthroplasty include female gender, posttraumatic arthritis, revision surgery, and developmental dysplasia of the hip [184]. The risk for sciatic nerve palsy increases with leg lengthening of more than 3 to 5 cm in patients with developmental dysplasia of the hip [184]. Lateral femoral cutaneous nerve injury is more common with the anterior approach to the hip, occurring in up to 20% of cases [184]. A hip hematoma from anticoagulation can cause sciatic nerve palsy via compression [184]. Use of tranexamic acid has become standard of care and has substantially reduced transfusion rates [184]. The mechanism of action of tranexamic acid is through inhibition of plasminogen and plasmin to bind to fibrin [184].

Soft Tissue and Capsular Pathology: Multiple mechanisms have been proposed to result in symptomatic iliopsoas tendinitis after total hip arthroplasty [344]. A subset of patients may present with idiopathic iliopsoas tendinitis after total hip arthroplasty without clear radiographic pathology or technical error [344]. The literature indicates a potential role for the hip joint capsule in mechanics via mechanoreceptors, though nomenclature is inconsistent and proprioceptive roles cannot be reliably confirmed [253]. No study has reported type I-III mechanoreceptors in the hip joint capsule [253].

Classification¶

Periprosthetic Fractures¶

Paprosky: This classification system is used for periprosthetic fractures of the acetabulum associated with total hip arthroplasty [1].

Unified Classification System (UCS): The UCS for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts [208].

Isolated Greater Trochanter Fractures: A new classification system for isolated greater trochanter fractures associated with total hip arthroplasty is based on fracture location relative to insertional anatomy [122].

BOSTI Hip: This classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during total hip arthroplasty [164].

Bone Stock and Deficiency¶

Femoral Reconstruction Algorithm: A classification system and algorithmic approach exists to guide femoral reconstruction in revision total hip arthroplasty based on the type of femoral deficiency [105].

Acetabular Bone Loss: A validated classification system for acetabular bone loss guides treatment and prognosticates outcomes in revision total hip arthroplasty [176].

Bone Stock Deficiency: A classification system and management strategies exist for bone stock deficiency in total hip replacement [145].

Mallory: This classification is used to grade preoperative femoral bone quality in revision total hip arthroplasty [294].

Implant and Component Design¶

Cementless Femoral Fixation: A basic classification system for cementless femoral fixation categorizes stems into six types based on design principles and methods of femoral preparation [333]. A separate classification should be considered for short-stem cementless designs that do not fit into the standard six categories [333].

Modular Hip Taper Connections: A new classification system regarding the surface finish of modular hip taper connections has been presented [150].

Femoral Stem Length: A classification system for the length of femoral stems has been suggested to organize discussion on stem length [153].

Preoperative and Patient-Specific Factors¶

Hip-Spine Classification: This system guides the use of dual-mobility components in patients with spinopelvic pathology to reduce the risk of dislocation [223].

Long-Term Unreduced Hip Joint Dislocation: A new classification system for total hip arthroplasty in patients with long-term unreduced hip joint dislocation helps surgeons estimate potential difficulties during surgery [10].

Revision Difficulty Score: A comprehensive score for predicting difficulties in revision total hip arthroplasty adds criteria to bone destruction, contrasting with widely used classifications for revision THA [154].

Charnley: This classification is used to decide intervention and inform patients of possible outcomes in total hip arthroplasty for patients aged 80 years or older [340].

ASA Physical Status: The ASA physical status classification system has been evaluated for its predictive ability on health-related quality of life after total hip replacement [205].

Complications and Outcomes Reporting¶

Hip Society: The Hip Society developed a standardized list, definitions, and stratification system for total hip arthroplasty complications and adverse events [21].

Modified Clavien-Dindo: This grading scheme is used to grade complications in total hip arthroplasty studies, focusing on treatments required to manage complications and their potential long-term impact [36].

McPherson: This classification is used to discriminate individual determining factors for infection type, host grade, and local extremity grade in prosthetic joint infection management [316].

Clinical Presentation¶

Indications and Patient Selection¶

The primary indication for total hip arthroplasty (THA) is the alleviation of incapacitating arthritic pain that cannot be relieved by non-surgical alternatives [7]. Surgery is justified when pain at rest and pain with motion or weight bearing are severe enough to prevent the patient from working or carrying out activities of daily living [7]. Pain in the presence of a degenerative or destructive process in the hip joint, as evidenced on imaging studies, constitutes the primary indication for surgery [7]. Conversely, patients with limitation of motion, limp, or leg-length inequality with little or no hip pain are not candidates for THA [7]. Conservative measures including weight loss, nonopioid analgesics, activity modification, low-impact exercise, and ambulatory aids should be advised before major reconstruction [7].

Historically, patients aged 60 to 75 years were considered the most suitable candidates for THA, but this age range has expanded since the 1990s [7]. The 1994 National Institutes of Health Consensus Statement concluded that THA is an option for nearly all patients with hip diseases causing chronic discomfort and significant functional impairment [7]. For young patients with osteoarthritis, femoral or periacetabular osteotomy should be considered if the joint is not grossly incongruous and satisfactory motion is present [7]. Arthrodesis remains a viable option for young, vigorous patients with unilateral hip disease, especially young, active men with osteonecrosis or posttraumatic arthritis [7].

THA is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone [23]. THA proved to be reliable for alleviating pain and improving function in patients with advanced symptomatic arthritis secondary to osteochondrodysplasia [39]. In the setting of severe symptoms and the absence of advanced osteoarthritis on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA [33]. A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy within 2 years [19].

Men and women undergoing THA have different clinical presentations before surgery, with females presenting with worse baseline conditions and showing relatively less improvement at 1-year postsurgery compared to males [35]. Patients who exhibited rapidly progressive osteoarthritis before undergoing THA showed worse patient-reported outcomes compared with those who did not have rapid progression [136]. An underlying diagnosis of osteonecrosis of bone is associated with worse outcomes than osteoarthritis after total hip arthroplasty [34]. However, osteonecrosis itself, or when associated with the most common risk factors and/or diagnoses, is not associated with poor outcomes in total hip arthroplasty [77]. Contemporary THA provides similar clinical benefits across both Crowe I developmental dysplasia of the hip and primary osteoarthritis diagnoses [30]. Adjustments for differences in age and prosthesis choice must be made when the results of hip arthroplasty are studied in different diagnostic groups [27]. Patients who present with or whose condition progresses to collapse of the femoral head will require treatment with a standard total hip arthroplasty [106]. The new classification system for long-term unreduced hip joint dislocation, secondary osteoarthritis, and pseudoarthrosis could help surgeons estimate potential difficulties during total hip arthroplasty [10]. Conversion THA results support the reclassification of conversion into a diagnosis-related group separate from primary THA [40].

Contraindications¶

Absolute contraindications for THA include active infection of the hip joint or any other region and any unstable medical illnesses that would significantly increase the risk of morbidity or mortality [7]. Asymptomatic bacteriuria has not been associated with postoperative surgical site infections and should not be considered a contraindication [7]. A documented patent ductus arteriosus or septal defect is an absolute contraindication for bilateral total hip procedures carried out under a single anesthetic [7]. Elderly patients with other comorbidities are not suitable candidates for bilateral total hip procedures carried out under a single anesthetic [7].

Evaluation of the Painful Hip¶

Evaluation of the painful hip after total hip replacement requires a careful elicitation of the patient's history and examination to distinguish between intrinsic and extrinsic sources of pain [79]. A systematic approach to the failed THA is paramount to identifying the correct diagnosis and selecting the proper treatment [111].

Pain Location: * Groin or buttock pain suggests an acetabular or a joint-centered problem [16]. * Anterior thigh pain suggests a femoral-side problem [16]. * Lateral hip pain suggests hip abductor weakness, trochanteric impingement, or inflammation such as bursitis or tendinopathy [16]. * Knee pain may indicate a hip condition, while patient-reported hip pain may be referred from the lumbar spine, abdomen, or retroperitoneum [16].

Temporal Patterns and Triggers: * Early-onset and/or unresolved pain may indicate infection, occult fracture, or a mechanically unstable prosthesis [16]. * Delayed-onset pain is more likely to be the result of a low-grade surgical infection, late hematogenous infection, bearing surface wear, synovitis, osteolysis, mechanical loosening, or stress shielding and loss of periprosthetic bone [16]. * Start-up pain or pain with prolonged ambulation is associated with weight-bearing activities [16]. * Pain while lying on the side suggests bursitis, abductor weakness, tendinopathy, or tear [16].

Specific Clinical Signs: * Prolonged drainage after surgery, fever, and chills are suggestive of infection [16]. * A history of hip dislocation suggests instability [16]. * Pain with active hip flexion may suggest psoas tendon irritation or anterior impingement [16]. * Hip abduction weakness may contribute to lateral hip pain and may originate from a neurologic condition, violation of hip abductors from surgery, or inadequate rehabilitation [16].

If the cause of persistent pain after a hip replacement is not obvious after a thorough history, physical examination, and plain radiographic evaluation, further investigation including serologic tests, sophisticated radiologic investigations, nuclear medicine scans, and microbiologic investigations is required [22]. The paper details the history, physical examination, and diagnostic workup of extra-articular sources of pain after total hip arthroplasty, including iliopsoas impingement, greater trochanteric pain syndrome, and deep gluteal space pathology [113]. Hip arthroscopy may be useful in the diagnosis and treatment of apparently well-implanted but unstable total hip replacement prostheses [12]. Hip arthroscopy after hip arthroplasty is uncommon but occurs more frequently in female patients, is undertaken in a broad age range of patients, and often is associated with a diagnosis of iliopsoas or hip tendinitis [128]. The differential diagnosis of persisting unusual symptoms after total hip replacement has to include a fistula between the total hip prosthesis and urinary tract, even in the absence of open sinuses [123]. Vascular injury during total hip replacement can present as an acute abdominal condition without pronounced local symptoms, leading to delayed treatment and fatal outcomes [139].

Imaging and Diagnostic Modalities¶

Plain radiographs should be taken in perpendicular planes, with the AP view allowing visualization of the contralateral hip [16]. Radiographic signs of loosening include component migration or subsidence, progressive or complete radiolucency, absence of spot welding, pedestal formation in the femur, and bone stock maintained in the femoral neck with calcar sclerosis [16]. Acetabular osteolysis is characterized by size and location using the Charnley and DeLee classification system, with zones 1 (superolateral), 2 (central), and 3 (inferomedial) [16]. Plain radiographs underestimate the severity of acetabular osteolysis [16]. Ancillary radiographs such as Judet views or CT scans are important to assess the integrity of the anterior and posterior columns [16]. Femoral osteolysis is characterized by size and location using the Gruen classification system, with zones 1 through 7 progressing from proximal/lateral distally to the tip of the implant and back up the medial side to the lesser trochanter [16].

CT provides assessment of component position and anteversion, the size and location of bone loss, and the quality and location of remaining bone, and may be useful for creating models for reconstruction or customized implants [16]. MRI with artifact reduction may be useful in identifying soft-tissue lesions around the hip joint [16]. Ultrasonography may be useful in identifying soft-tissue masses around failed implants [16]. Nuclear medicine may indicate the presence of components that are not osseointegrated [16]. X-rays taken immediately after surgery rarely reveal unknown complications in total hip arthroplasty [25]. A novel technology may help clinicians objectively define a diagnosis of impingement in total hip prostheses in the absence of other clinically identifiable sources of pain [20]. Patient history, physical examination, and radiological studies provide the surgeon with almost all the data required to stratify a patient according to risk for postoperative THA instability [118].

Laboratory Assessment¶

The erythrocyte sedimentation rate (ESR) is a nonspecific indicator of a chronic or acute inflammatory state, with levels greater than 20 mm/hr suggesting an inflammatory state [16]. The C-reactive protein (CRP) level is a nonspecific indicator of acute infection and usually normalizes within 3 weeks of surgical intervention, with levels greater than 7.0 mg/L suggesting an acute inflammatory process [16]. Complete blood cell count with differential may be elevated with systemic infection or illness [16].

For chronic postoperative joint aspiration, a white blood cell (WBC) count greater than 2,500 cells/mL and polymorphonuclear leukocytes (PMNs) greater than 90% are indicative of infection [16]. For acute postoperative joint aspiration, a WBC count greater than 27,000 cells/mL and PMN values greater than 90% are indicative of infection [16]. Lower PMN values may be considered if the clinical picture supports infection, such as elevated ESR or CRP level [16]. The diagnosis of infection following total hip arthroplasty relies on the surgeon's judgment of the clinical presentation, physical examination findings, and interpretation of previous investigations, as no single test is 100 percent sensitive and specific [75]. The final diagnosis of infection is based on the interpretation of the clinical presentation and preoperative and intraoperative findings rather than on a single test [125]. A diagnosis of periprosthetic joint infection is made when the patient meets at least one of three criteria: an open wound or sinus in communication with the joint, a systemic infection with pain in the hip and purulent fluid within the joint, or a positive result on at least three tests where either histological evaluation or intraoperative cultures had to be positive [125].

Metal-on-Metal and Adverse Local Tissue Reactions¶

There should be a low threshold to conduct a systematic clinical evaluation of patients with metal-on-metal hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment [88]. Adverse reaction to metal debris may occur with hip reconstructions performed with large metal-on-metal articulations, dual-modular femoral necks, and/or large diameter femoral heads [16]. The review evaluates the incidence, pathogenesis, diagnosis, and treatment of trunnionosis in metal-on-polyethylene total hip arthroplasty, noting that the true incidence is likely underreported due to variable clinical presentations and unclear pathogenesis [141]. Impingement is a cause of poor outcomes of prosthetic hip arthroplasty; it can lead to instability, accelerated wear, and unexplained pain [126].

Periprosthetic Fractures¶

The incidence of periprosthetic fracture of the acetabulum occurring during primary THA with cemented acetabular components is 0.2% [1]. The incidence of periprosthetic fracture of the acetabulum occurring during primary THA with noncemented acetabular components is 0.4% [1]. Intraoperative risk factors for acetabular fracture include noncemented acetabular components, underreaming by more than 2 mm, elliptical monoblock components, osteopenia or osteoporosis, Paget disease, and removal of acetabular components at revision [1]. Postoperative acetabular fracture should be suspected if groin pain is present after trauma [1]. Plain radiographs may underestimate bone loss in acetabular fractures [1]. The fracture line may be obscured by metallic components on plain radiographs [1].

The incidence of intraoperative periprosthetic femoral fracture in primary THA is 0.1% to 5.4% [1]. The incidence of intraoperative periprosthetic femoral fracture in revision THA is 3.0% to 20.9% [1]. Risk factors for periprosthetic femoral fracture include revision surgery, noncemented press-fit technique, compromised bone stock, and impaction grafting technique [1]. A minimum of two views (AP and lateral) are obtained to help identify the type and extent of periprosthetic femoral fractures [1]. Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment [114]. Early periprosthetic femoral fracture after total hip arthroplasty is not simply the same fracture occurring sooner but represents a distinct clinical phenotype defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity [140].

Revision Indications¶

In determining the need for revision of painful THA, the patient must be evaluated to determine whether symptoms are the result of failed THA or other problems including spinal disease, tumor, vascular occlusion, stress fracture, or complex regional pain syndrome [9]. Pain is the major indication for revising a THA [9]. The most common indications for revision hip replacement are dislocation, mechanical loosening, other mechanical problems, infection, osteolysis, periprosthetic fracture, wear, and implant failure or breakage [9]. Pain associated with loose total hip components typically occurs with the first few steps a patient takes, known as start-up pain [9]. A loose acetabular component usually produces pain in the groin, whereas a loose femoral component may cause pain in the thigh or knee [9]. Revision is indicated for progressive stem deformation or incomplete fracture [9]. Operative diagnosis is independently associated with activities of daily living limitations, but not pain, at 2-years after revision THA [133]. Focusing on primary THAs initially performed by a contemporary, subspecialty practice allowed an accurate determination of etiologies and rates of failure after THA [26].

Postoperative Monitoring and Adverse Events¶

Almost one-third of adverse events following total hip arthroplasty were diagnosed between postoperative days 31 and 90, highlighting the importance of looking beyond 30 days when estimating patients' risk of postoperative adverse events [32]. This article highlights common causes of early revision total hip arthroplasty and provides specific technical strategies to avoid complications [17].

Investigations¶

History and Physical Examination¶

The clinical presentation of pain following total hip arthroplasty localizes the pathology. Groin or buttock pain suggests an acetabular or joint-centered problem [16], while anterior thigh pain indicates a femoral-side issue [16]. Lateral hip pain points to hip abductor weakness, trochanteric impingement, or inflammation such as bursitis or tendinopathy [16]. Hip abduction weakness may contribute to lateral pain and may originate from neurologic conditions, surgical violation of hip abductors, or inadequate rehabilitation [16]. Neurologic assessment of motor and sensory function identifies peripheral nerve injury or concurrent lumbar radiculopathy [16], and vascular assessment including distal pulses, warmth, and perfusion is part of the physical examination [16].

The timing of pain onset guides the differential diagnosis. Early-onset or unresolved pain may indicate infection, occult fracture, or a mechanically unstable prosthesis [16]. Delayed-onset pain is more likely to result from low-grade surgical infection, late hematogenous infection, bearing surface wear, synovitis, osteolysis, mechanical loosening, stress shielding, or loss of periprosthetic bone [16]. A history of multiple surgical procedures is associated with increased risks of infection and instability [16], and treatment with antibiotics after surgery suggests infection [16]. Postoperative fracture of the acetabulum should be suspected if groin pain is present after trauma [1].

Plain Radiography¶

Plain radiographs are the initial imaging modality, though they may underestimate bone loss in the evaluation of periprosthetic acetabular fractures [1]. Fracture lines in the acetabulum may be obscured by metallic components on plain radiographs [1]. Judet views, including obturator and iliac oblique radiographs, may help identify anterior or posterior column fractures of the acetabulum [1]. For periprosthetic femoral fractures, a minimum of two views, specifically AP and lateral, are obtained to help identify the type and extent of the injury [1]. Radiographs should be taken in perpendicular planes, with the AP view allowing visualization of the contralateral hip [16].

Radiographic signs of loosening include component migration or subsidence, progressive or complete radiolucency, absence of spot welding, pedestal formation in the femur, and bone stock maintenance in the femoral neck with calcar sclerosis [16]. Acetabular osteolysis is characterized by size and location using the Charnley and DeLee classification system, which defines Zone 1 as superolateral, Zone 2 as central, and Zone 3 as inferomedial [16]. Femoral osteolysis is characterized by size and location using the Gruen classification system, which defines Zones 1 through 7 progressing from proximal/lateral distally to the tip of the implant and back up the medial side to the lesser trochanter [16]. Plain radiography had the highest diagnostic accuracy in the evaluation of aseptic loosening of the acetabular component [349].

Both radiographic methods enable a simple orientation and a practical conventional radiographic estimation of stem torsion on hip radiographs after total hip arthroplasty [284]. Using digital radiography in conjunction with strict impingement testing allows for predictable cup placement in total hip arthroplasty, positioning the acetabular component within the desired target zone in 97.8% of cases [334]. Weight-bearing imaging is a critical adjunct to traditional supine radiographs for optimizing total hip arthroplasty component position to prevent instability and early wear [336]. Patients awaiting total hip arthroplasty with combined high hip and reduced lumbar spine mobility can be screened using lateral standing radiographs of the spinopelvic complex [346]. Heterotopic ossification is a common radiographic finding after modern total hip arthroplasty, with prevalence ranging from 10% to 40% depending on the surgical approach [314]. AI-based analyses can accurately and consistently evaluate postoperative total hip arthroplasty radiographs [348]. Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary total hip arthroplasty [256].

Advanced Imaging¶

CT: CT is seldom needed for periprosthetic acetabular fractures but may help visualize fractures not identified using other imaging methods [1].

Bone scan: Bone scans may help identify late periprosthetic acetabular fractures not seen on plain radiographs [1].

MRI: Selective use of MRI could be invaluable in directing the care of patients after hip arthroplasty [166]. Magnetic resonance imaging can be used to directly evaluate the integrity of metallic components and detect occult fractures of the femoral component after total hip arthroplasty, even when plain radiographs are normal [199]. Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans [224]. MRI can effectively diagnose posterior capsular disruption in patients who have undergone total hip arthroplasty via a posterior approach [304]. MRI can accurately describe adverse local tissue reaction in modular femoral neck total hip arthroplasty [307]. MARS-MRI is as suitable as standard diagnostic tools to distinguish between aseptic failure and periprosthetic joint infection in patients with total hip arthroplasty [361]. The combined imaging diagnostic criteria for aseptic loosening of the acetabular cup after total hip arthroplasty demonstrate superior diagnostic efficacy compared to single imaging parameters [271]. After total hip arthroplasty, acetabular component position can be evaluated using a variety of imaging techniques [292]. In the setting of severe symptoms and the absence of advanced osteoarthritis on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from total hip arthroplasty [33].

Laboratory Assessment¶

Laboratory: An erythrocyte sedimentation rate greater than 20 mm/hr suggests an inflammatory state [16], and a C-reactive protein level greater than 7.0 mg/L suggests an acute inflammatory process [16]. A complete blood cell count with differential may be elevated with systemic infection or illness [16]. Diagnosis of trunnionosis is made based on a serum cobalt level greater than 1 ppb and cobalt ions significantly greater than chromium ions [8]. Metal ion analysis should be used in conjunction with clinical and imaging evaluation and not as a sole indirect screening test when evaluating patients following metal-on-metal hip arthroplasty [331].

Aspiration: For chronic postoperative joint aspiration, a white blood cell count greater than 2,500 cells/mL and polymorphonuclear leukocytes greater than 90% are indicative of infection [16]. For acute postoperative joint aspiration, a white blood cell count greater than 27,000 cells/mL and polymorphonuclear leukocyte values greater than 90% are indicative of infection [16]. Lower polymorphonuclear leukocyte values may be considered if the clinical picture supports infection, such as elevated erythrocyte sedimentation rate or C-reactive protein level [16].

Other Considerations¶

If the cause of persistent pain after a hip replacement is not obvious after history, physical examination, and plain radiographic evaluation, further investigation is required using serologic tests, sophisticated radiologic investigations, nuclear medicine scans, and microbiologic investigations to rule out occult infection [22]. National implant registers define the epidemiology of primary and revision surgery and, in conjunction with individual subjective patient data and radiography, contribute to the development of evidence-based total hip arthroplasty surgery [14]. Arthrography casts doubt on the significance of arthrographic evidence of loosening in the evaluation of the cause of pain after total hip replacement [366]. Intraoperative trabecular torque measurements may function as an intraoperative alternative to DXA in total hip arthroplasty, though more research and clinical trials are necessary before clinical use [360].

Treatment¶

Non-Operative¶

Total hip arthroplasty is indicated when pain at rest and with motion or weight bearing prevents work or activities of daily living despite conservative measures [7]. In younger individuals, hip preservation options such as femoral or periacetabular osteotomy may delay or obviate the need for arthroplasty [7]. Arthrodesis is a viable option for young, vigorous patients with unilateral hip disease, especially young, active men with osteonecrosis or posttraumatic arthritis [7]. Some designs of hip resurfacing remain an alternative to THA in young, active men [7].

Operative¶

Indications: THA is an effective treatment for hip conditions in children, though it carries a higher than normal incidence of revision surgery [138]. THA is a cost-effective option compared to non-operative management in patients 80 years old and older [237]. Nonagenarians undergoing primary THA have substantial mortality rates at 90 days (6%) and 1 year (8%) [53]. THA is a safe and feasible option for head and neck of femur fractures secondary to civilian gunshot injuries that carry poor surgical fixation outcomes [192]. THA may be considered for younger and more active patients with displaced femoral neck fractures based on expert opinion [38]. Primary total hip replacement may be the management of choice in rheumatoid patients and for young patients unsuitable for internal fixation of displaced subcapital femoral fractures [207]. THA is a reasonable treatment modality for patients with labral tears who fail nonoperative treatments, given suboptimal outcomes with hip arthroscopy in the setting of early arthritis [252]. The presence of cerebral palsy is not a contraindication for total hip replacement for a painful deformed or degenerated hip [121]. THA provided systematic alleviation of pain and did not aggravate functional status in non-ambulatory cerebral palsy patients [282]. THA for non-ambulatory patients with cerebral palsy carries a high complication rate (35%) and risk of revision, requiring caution and a multidisciplinary team approach [291]. THA is effective for the treatment of high dislocation of the hip in adults [100]. THA is feasible for the treatment of the three types of congenital hip disease when anatomical abnormalities are understood and appropriate techniques are used [24]. THA for developmental dysplasia of the hip is a technically demanding surgery requiring an in-depth understanding of anatomical abnormalities and complex techniques [69]. Patients with limitation of motion, limp, or leg-length inequality but little or no hip pain are not candidates for THA [7]. Active infection of the hip joint or any other region is an absolute contraindication for THA [7]. Unstable medical illnesses that significantly increase the risk of morbidity or mortality are absolute contraindications for THA [7]. Asymptomatic bacteriuria is not associated with postoperative surgical site infections and is not a contraindication for THA [7]. A documented patent ductus arteriosus or septal defect is an absolute contraindication for bilateral total hip procedures under a single anesthetic [7]. THA in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable [18]. Joint-preservation techniques should be utilized in very young patients to facilitate future hip arthroplasty surgery [90].

Surgical Approach / Technique: The direct anterior approach (DAA) is utilized by more than 25% of US surgeons for primary hip arthroplasties [2]. The direct anterior approach uses the distal half of the traditional Smith-Petersen approach and is both intermuscular and internervous [55]. The direct anterior approach can be performed on a conventional radiolucent table or a specialized table [55]. Access to the femur is more difficult with the direct anterior approach, leading many surgeons to use shorter or curved femoral components [55]. The interval for the direct anterior approach cannot be safely extended distally, requiring separate exposure for femoral access in patients with deformity or previous implants [55]. Concerns remain about an increase in early complications with anterior approach surgery, particularly femoral complications such as periprosthetic fracture, subsidence, and failure of osteointegration [2]. Large registry and multi-institution studies have shown the anterior approach can be performed safely without an increase in complications in experienced hands [2]. The direct anterior approach has been associated with a higher rate of femoral problems, including fracture and loosening [272]. A modified direct anterior approach preserves the benefits of the anterior approach while addressing practical limitations such as the need for a traction table and specialised equipment [84]. The ASI (anterior superior iliac) approach is a safe, minimally invasive method for performing primary total hip replacement that encourages early functional recovery [102].

The posterolateral approach is a modification of posterior approaches described by Gibson and Moore [46]. The posterolateral approach can be extended proximally by osteotomy of the greater trochanter with anterior dislocation of the hip [46]. The posterolateral approach can be extended distally to allow a posterolateral approach to the entire femoral shaft [46]. The posterolateral approach is used for primary and revision THA [46]. The posterior approach has been associated with a higher rate of dislocation [272]. The mini-posterior approach has the same structures at risk as the standard posterolateral approach [5]. The mini-posterior approach has an increased potential for component malpositioning compared to the standard posterolateral approach [5].

The two-incision anterior approach uses an anterior incision for acetabular insertion and a lateral incision for the femoral component [5]. The two-incision approach is technically difficult and does not allow wide exposure of the hip joint [5]. The two-incision total hip arthroplasty is a technically demanding procedure that requires careful patient selection, preoperative templating, and attention to details to avoid potential complications [82]. Every two-incision total hip replacement caused measurable damage to the abductors, the external rotators, or both in cadaver studies [273]. Damage to the muscle of the gluteus medius and gluteus minimus was substantially greater with the two-incision technique than with the mini-posterior technique in cadaver studies [273].

The lateral (Hardinge) approach involves splitting the gluteus medius at the junction of the anterior third and posterior two-thirds [5]. The lateral (Hardinge) approach has a postoperative limp incidence of 18% in primary THA [5]. Heterotopic ossification incidence is as high as 47% in primary THA with the lateral (Hardinge) approach [5]. Trochanteric nonunion rates for the lateral (Hardinge) approach are reported between 5% and 32% [5]. The anterolateral (Watson-Jones) approach has a low incidence of postoperative dislocation [5]. The anterolateral (Watson-Jones) approach carries a risk of damage to the femoral shaft and malpositioning of the femoral implant during femoral canal preparation [5]. Abductor sparing approaches through the Watson Jones muscle interval have gained popularity as an alternative to the DAA with similar lower pain levels and faster recovery [2]. The anterior (Smith-Petersen) approach allows hip dislocation without risk to the femoral head blood supply [5]. Extensive release of the abductors in the anterior approach can result in weakness and a high incidence of heterotopic ossification [5].

All three surgical approaches (posterior, direct lateral, and direct anterior) are safe and have excellent results in patients undergoing primary total hip arthroplasty [72]. Promoting one surgical approach over another is marketing without substantial proof of superiority; surgical technique, clinical experience, and modern-day pathways play the most substantial roles in providing excellent care [66]. Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience [91]. The direct anterior approach may be comparable to other total hip arthroplasty approaches, but there is no evidence to date that shows improved long-term outcomes for patients [80]. Patients who received primary THA via the direct anterior approach were more likely to receive revision THA via a discordant approach compared to other primary approaches [70]. Revision total hip arthroplasty through the direct anterior approach is technically challenging but offers advantages in exposure of the acetabulum and can yield generally good postoperative function [73]. Minimally invasive total hip arthroplasty is a safe procedure in skilled hands that does not increase complication rates compared to traditional approaches [76]. Different surgical approaches have different advantages and disadvantages, although no clear difference in patient outcomes has been established [272].

Implant Selection: No implant design or system is appropriate for every patient; selection is based on patient needs, anticipated longevity, activity level, bone quality, dimensions, implant availability, and surgeon experience [6]. Porous-coated cementless cups are the preferred choice for acetabular fixation [49]. Porous-coated hemispheric cementless cups have reliable long-term results that are superior to cemented cups [49]. Both cementless and cemented fixation methods are acceptable techniques in primary THA for the femoral stem [49]. Cementless stem indications include high-activity-level patients and young male patients, as cement would cyclically fatigue over time or crack at stress points [49]. Cemented stems have a lower risk of periprosthetic fracture in patients with poor bone (often elderly females) and Dorr C anatomy [343]. Cemented stems are generally considered the “gold standard” for hip fractures [343]. Cementation of the femoral stem in hip fracture patients may facilitate better postoperative mobilization [343]. In patients older than 65 years undergoing primary THA, cemented femoral fixation resulted in the lowest incidence rate of early periprosthetic femoral fracture [197]. While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients [160]. Uncemented and antibiotic-loaded cemented fixations remain options for the prevention of prosthetic joint infection in primary total hip replacement [211].

Bone ingrowth requires live host bone, an appropriate ingrowth surface on the implant, and initial rigid fixation [272]. Motion of the prosthesis within the bone will lead to fibrous fixation or encapsulation [272]. Hydroxyapatite is an osteoconductive surface coating that may shorten the time to biologic fixation [272]. Femoral stress shielding leads to loss of proximal bone density and results from modulus mismatch between stem and femoral bone [272]. Femoral stem breakage occurs from cantilever bending [272]. The results of a porous-coated anatomic total hip arthroplasty without cement at fifteen years encouraged the continued use of cementless fixation in total hip arthroplasty [181]. A straight-stemmed, plasma-sprayed, titanium-alloy, uncemented femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty [147]. Implant survivorship at 2, 5, and 10 years for a specific uncemented primary THA system is among the best reported for any total hip system in the world [48]. The Corin C-Fit uncemented total hip arthroplasty implant should not be used, and patients who have had this form of THA should be kept under regular review [156]. Because of reported higher risks, there is no clear indication for modularity with a primary THA unless the hip center cannot be achieved with a nonmodular stem [41]. The incidence of implant fractures after total hip arthroplasty in worldwide arthroplasty register datasets is 304 fractures per 100,000 implants [43]. One out of 323 patients undergoes revision surgery due to an implant fracture after THA in their lifetime [43].

Bearing Surfaces: Utilization of metal-on-metal bearings in primary THA decreased from 39.2% to 5.5% between 2007 and 2015 [2]. Utilization of ceramic-on-polyethylene bearings in primary THA increased from 6.4% to 52.0% between 2007 and 2015 [2]. There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients [137]. Gender factors influence the success of metal-on-metal THA, leading to expanded contraindications to avoid this device in female patients [132]. All patients undergoing metal-on-metal implantation since 2006 and those with bilateral metal-on-metal hips should undergo regular investigation, regardless of symptoms [143]. Increased femoral head size (>36 mm) has been associated with an increased incidence of groin pain [8]. Mechanical noise incidence after THA is between 0.2% and 17.0% [8]. Audible mechanical noise has not been associated with implant failure or revision [8]. Trunnionosis diagnosis is made based on serum cobalt level > 1 ppb and cobalt ions >>> chromium ions [8]. Selection of a ceramic femoral head in primary THA may reduce the risk for trunnionosis [8].

Pain Management: Tranexamic acid (TXA) has become standard-of-care at most institutions performing hip arthroplasty given its benefit in reducing surgical blood loss and subsequent transfusions [15]. Oral TXA was equally effective as IV administration but at a greatly reduced cost in a 2017 RCT [15]. A combined IV and topical application of TXA reduced total blood loss by an additional 200 mL compared with the single IV dose group in a 2016 RCT [15]. No orthopaedic study has yet demonstrated concern for an increase in venous thromboembolic (VTE) events in the setting of TXA administration [15]. Aspirin has a lower risk of major and minor bleeding complications and lower rates of incisional complications compared with alternative means of chemoprophylaxis [15].

Revision: Noncemented biologic fixation remains the benchmark for revision THA [317]. Modular and nonmodular fluted tapered stems offer reliable fixation even in cases where bone stock is significantly compromised during revision THA [317]. A 2017 single-institution study reported a 96% 10-year survivorship among 519 aseptic femoral revisions where a modular fluted tapered stem was utilized [317]. Noncemented hemispherical highly porous acetabular cups with supplemental screw fixation are sufficient for most acetabular revisions [317]. Porous tantalum acetabular cup and augment constructs offer the potential for excellent long-term fixation for major acetabular bone loss [317]. A 2017 study reported 97% survivorship at 5 years among 85 hips revised with significant acetabular bone loss using a porous tantalum construct [317]. Cup-cage constructs have shown excellent short-term results for complex acetabular defects, including those with concurrent pelvic discontinuity [317]. Custom triflange constructs and pelvic distraction remain good options for complex acetabular defects [317].

Complications¶

Periprosthetic fracture: Acetabular periprosthetic fracture occurs in 0.2% of primary total hip arthroplasty cases with cemented components and 0.4% with noncemented components [1]. Intraoperative risk factors include noncemented press-fit components, underreaming by more than 2 mm, elliptical monoblock components, osteopenia or osteoporosis, Paget disease, and component removal at revision [1]. Postoperative risk factors include trauma, osteolysis, and osteopenia or osteoporosis [1]. Intraoperative femoral fracture incidence ranges from 0.1% to 5.4% in primary total hip arthroplasty and 3.0% to 20.9% in revision total hip arthroplasty [1]. Prophylactic cerclage wires and cortical onlay strut allografts are recommended to reduce fracture risk associated with impaction grafting [1]. Ten years after primary total hip replacement, periprosthetic fractures occur annually in 26 per 10,000 persons, with higher frequency in patients with prior total knee or revision total hip replacements [371]. The cumulative incidence of periprosthetic femoral fracture after primary uncemented total hip arthroplasty increases in the second decade and reaches the incidence of aseptic stem loosening in the third decade [353]. No specific risk factors were identified in a minimum 20-year follow-up of uncemented total hip arthroplasty [353]. In postmenopausal women, preoperative hormone replacement therapy was associated with lower rates of periprosthetic fracture within 10 years and did not increase venous thromboembolism risk [401]. Early periprosthetic femur fractures are associated with greater incidences of periprosthetic joint infections and overall reoperations compared to late fractures [407].

Other Considerations: In a series of 301 dysplastic hips treated with cementless total hip arthroplasty and Paavilainen femoral shortening osteotomy, uncontrolled intraoperative cracks of the distal femoral fragment occurred in 14 hips (4.2%), all treated with cerclage wires [323]. In a single surgeon’s experience with the 2-incision technique, 4 intraoperative and 4 postoperative femur fractures occurred in the first 200 cases [325]. Additionally, 2 nondisplaced greater trochanter fractures greater than 2 cm and 14 asymptomatic greater trochanter fractures 2 cm or less occurred in the same cohort [325]. In a systematic review of total hip arthroplasty for sequelae of Legg–Calvé–Perthes disease, intra-operative fracture occurred in 11% of cases, all when standard stems were used [305]. Nineteen of 27 intra-operative fractures were treated with cables and wires, and 8 with restricted weight bearing; none required revision total hip arthroplasty [305]. In a prospective randomized study of displaced subcapital fractures, 1 iatrogenic femoral fracture occurred in the total hip arthroplasty group [321]. A retrospective case-control study of 199 hips comparing dual mobility total hip arthroplasty and bipolar arthroplasty for femoral neck fractures found no significant differences in medical complications [93]. However, the rate of life-threatening complications was higher in the bipolar arthroplasty group (10) than in the total hip arthroplasty group (2) before adjustment [93]. In a contemporary series of 104 patients undergoing total hip arthroplasty following prior open reduction internal fixation of an acetabular fracture, 2 periprosthetic femur fractures occurred without leading to reoperation [332]. Ten-year survivorships free of any revision and any reoperation were 98% and 97%, respectively [332]. Four revisions occurred: 1 each for psoas tendonitis, dislocation, acetabular aseptic loosening, and periprosthetic joint infection [332]. Five dislocations, 1 sciatic nerve palsy, and 1 case of symptomatic heterotopic ossification occurred as complications that did not lead to reoperation [332].

In a study of total hip arthroplasty with an uncemented tapered femoral component in patients younger than 50 years, primary total hip arthroplasty was associated with a high rate of survival at 29 years [299]. Primary total hip arthroplasty is associated with a low rate of aseptic loosening at a mean follow-up of twenty years [300]. The long-term outcome of cemented primary and subsequent revision total hip arthroplasty is promising in these young patients [350]. In a study of contemporary aseptic revision total hip arthroplasty in patients 50 years of age or younger, the re-revision risk was approximately 1 in 4 at 20 years [372]. In a study of total hip arthroplasty in patients with ankylosing spondylitis, the 20-year cumulative incidence of any revision after primary total hip arthroplasty was 17.5% [335]. In a study of long-term outcomes of functional cup positioned total hip arthroplasty in Asian ankylosing spondylitis patients, primary total hip arthroplasty demonstrated favorable survival at 10 years but poor long-term survival [64].

In a study of total hip arthroplasty in patients with femoral neck fracture, the pooled incidence for total hip arthroplasty due to fractured neck of femur is 9.7 per 100,000 over the included countries [85]. Incidence rates across the countries varied with a reported range from 6.7 to 16.0 per 100,000 [85]. The 8 arthroplasty registers included in the study involve a total number of 11,686 primary total hip arthroplasties after fractured neck of femur [85]. The total number of primary total hip arthroplasties after fractured neck of femur in the registers is 8 times higher than the total set of data from all selected clinical studies [85]. The best evidence showed, with moderate certainty, that hemiarthroplasty and total hip arthroplasty likely result in similar revision rate, function, mortality, periprosthetic fracture, and dislocation at up to 5 years [432]. The best evidence showed a small, possibly unimportant benefit in health-related quality of life with total hip arthroplasty compared to hemiarthroplasty [432]. The incidence of secondary procedures did not differ significantly between patients undergoing total hip arthroplasty and hemiarthroplasty [384]. Total hip arthroplasty provided a statistically significant but clinically unimportant improvement in function and quality of life over 24 months compared to hemiarthroplasty [384].

In a study of total hip arthroplasty in patients with femoral neck fracture, women undergoing primary total hip arthroplasty for hip fracture have lower in-hospital mortality compared to men [107]. Treatment of hip fracture with total hip arthroplasty is associated with reduction in morbidity and mortality [107]. Compared to elective total hip arthroplasty, patients undergoing total hip arthroplasty for hip fracture had higher adjusted odds of mortality and of postoperative complications [107]. Older age, increased Charlson comorbidity score, Medicare payer status, race, weekend admission, and a Southern hospital region were significant predictors of inpatient mortality [107]. Patient sex was reported as a significant factor associated with total hip arthroplasty outcomes [107]. Male hip fracture patients are younger and have higher comorbidity burden compared to female hip fracture patients [107]. There is excess morbidity in males [107]. Comorbidity and sex were significant factors associated with mortality [107].

In a study of total hip arthroplasty in patients with femoral neck fracture, the mean age of the trial population was 63.7 ± 4.2 years, and 68% were women [108]. A larger proportion of patients in the internal fixation group were current smokers and diagnosed with osteoporosis compared with those in the total hip arthroplasty group [108]. Three patients were lost to follow-up, and 1 patient in each group died during the follow-up period [108]. Total hip arthroplasty leads to better results after low-energy displaced femoral neck fracture in patients aged 55 to 70 years [108]. The average Harris hip score amongst survivors at 13 years was 80 in the total hip arthroplasty group, 55 in the hemiarthroplasty group, and 62 in the internal fixation group [321]. The mortality rate at 12 months was 23% in the total hip arthroplasty group, 27% in the internal fixation group, and 81% in the hemiarthroplasty group [321]. The mortality rate at 13 years was 81% in the total hip arthroplasty group [321]. Two patients in the total hip arthroplasty group needed revision for infection and 4 for recurrent dislocation, making an overall revision rate of 6.75% [321]. Patients in the total hip arthroplasty group had a 20% dislocation rate [321]. Eighteen patients in the total hip arthroplasty group suffered dislocations, of whom 5 suffered recurrent dislocations [321]. Twenty-three patients in the internal fixation group had the internal fixation revised to total hip arthroplasty within the first year [321]. Seven more patients in the internal fixation group had hips revised to total hip arthroplasty during subsequent years [321]. Revisions in the internal fixation group were necessary because of nonunion of fracture, failure of fixation, femoral head collapse or avascular necrosis [321]. Twenty-two patients in the hemiarthroplasty group underwent revision, with 19 to a total hip arthroplasty for acetabular erosion, loosening, heterotopic ossification and 3 to a Girdlestone excision arthroplasty for deep infection [321]. There was a 13% dislocation rate in the hemiarthroplasty group before revision surgery [321]. Two pulmonary embolisms, 3 myocardial infarctions, 6 perioperative deaths, 1 peroneal nerve palsy, and 1 iatrogenic femoral fracture occurred as perioperative complications [321].

The change from preoperative mobility grade at 1 year was none in 49% of the total hip arthroplasty group, -1 in 24%, and -2 in 13% [321]. The change from preoperative mobility grade at 13 years was none in 53% of the total hip arthroplasty group, -1 in 17%, and -2 in 30% [321]. The change from preoperative mobility grade at 1 year was none in 57% of the internal fixation group, -1 in 17%, and -2 in 13% [321]. The change from preoperative mobility grade at 13 years was none in 33.3% of the internal fixation group, -1 in 0%, and -2 in 33.3% [321]. The change from preoperative mobility grade at 1 year was none in 30% of the hemiarthroplasty group, -1 in 33%, and -2 in 37% [321]. The change from preoperative mobility grade at 13 years was none in 23% of the hemiarthroplasty group, -1 in 30%, and -2 in 47% [321].

Recovery¶

Light activity (weeks): Most patients undergoing right total hip arthroplasty recover sufficient hip function to return to driving 4 to 6 weeks postoperatively [110]. With modern surgical techniques and rehabilitation protocols, patients can, on average, return to safely braking a vehicle approximately 2 weeks after right total hip arthroplasty [270].

Full activity (months): The majority of patients undergoing total hip replacement can expect to return to work and sporting activities within 4-6 months [151]. Most patients are able to return to preoperative levels of low- and moderate-impact sports between 7 and 12 months after total hip arthroplasty [218]. At a minimum five-year follow-up, most patients who underwent DAA THA successfully returned to sporting activities, typically within six months postoperatively [411].

Rehabilitation protocol: After implementation of the 'fast-track' rehabilitation protocol, the mean length of hospital stay for primary total hip arthroplasty decreased from 4.6 to 2.9 nights for unselected patients [159]. A rapid rehabilitation protocol is safe and fulfills the potential benefits of a rapid recovery with minimally invasive total hip arthroplasty [225]. These data suggest that rapid discharge following total hip arthroplasty can be performed safely in select patients older than 70 [239]. A majority of Medicare patients will continue to require inpatient hospitalization during their immediate recovery after THA [249]. Postoperative physical therapy remains an essential component of standard care following total joint arthroplasty, but the specific approach should be individualized [214]. This randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required [280]. In patients having unilateral total hip replacement, supervised and independent postdischarge rehabilitation did not differ for improving pain and function [251]. Standard physiotherapy rehabilitation in the UK after total hip replacement is variable and appears to rarely include progressive resistance training (PRT) [268]. We recommend self-efficacy-enhancing interventions to be combined with routine care soon after hip replacement [276]. Short-term recovery favors limited incision over standard incision THA [440].

Functional milestones: After surgery, individuals with total hip arthroplasty displayed a persistent increased contralateral shift as compared to controls, indicating the need for rehabilitation focused on normalizing loading of the limbs [259]. These results support the conclusion that six months following surgery, the gait of the majority (85%) of THA patients has not returned to normal [413]. Maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA [437]. The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes [422]. Poor recovery following the first THA was highly predictive of second-side failure [426].

Other Considerations: Sixty-nine percent of the original hip replacements were functioning well at the latest follow-up examination or at the time of death, and only 5% required more than one revision arthroplasty in patients less than fifty years old [50]. Although 63% of the original hip replacements were functioning at the latest follow-up or at the time of death, a significant decrease in activity level was seen over time in patients less than fifty years old [392]. Primary THA in AS patients demonstrated favorable survival at 10 years but poor long-term survival [64]. Total hip arthroplasty proved to be reliable for alleviating pain and improving function in patients with advanced symptomatic arthritis of the hip secondary to osteochondrodysplasia [39]. At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017 [13]. Survivorship for revision total hip arthroplasty using second revision as an endpoint was 82% at 10 years [63]. Patients reported higher rates of worsening and lower rates of improvement following revision total hip arthroplasty than primary total hip arthroplasty, with significantly less score improvement and lower postoperative scores for all patient-reported outcome measures after revision [51]. Despite greater improvements on PROMs from preoperative to postoperative, patients undergoing early revisions after primary THA perceive significantly higher levels of pain and worse physical functionality at 1-year of follow-up [419]. Functional improvement occurred after total hip arthroplasty among all studies, but obese patients generally did not attain the same level of physical function by the follow-up time point [267]. Patients who had prior lumbar spine surgery who underwent primary THA demonstrated equivalent improvements in PROs, but achieved lower overall postoperative scores and met hip arthroplasty thresholds at lower rates [436]. Variable functional recovery and a relatively high complication rate, particularly with tapered stems, warrant caution in Crowe Type IV dysplasia, and surgeons should set realistic expectations, as not all patients achieve optimal results [435]. Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup [434]. Patients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia [438]. The majority of patients report high levels of expectation fulfilment following THA at late follow-up [261]. While THA patients had more severe pain preoperatively, they experienced more immediate improvements in their pain outcomes, achieved an earlier plateau in their scores, and had lower postoperative pain than TKA patients [395]. At one year after primary THA, at least 13% of Danish patients experienced moderate to severe postsurgical pain [264]. The majority of patients return to work after THA, and some patients are able to start working after surgery [172]. Total hip arthroplasty has positive effects on work capacity in patients who return to work [190]. Fifty-nine percent of patients returned to some form of recreational activity after total hip arthroplasty [187]. Hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play [203]. Total hip arthroplasty is unlikely to significantly deleteriously affect participation and performance in golf after an appropriate period of recovery, with patients having a good chance of returning to play approximately 6 months after operation [255]. Most patients resumed or exceeded preoperative activity, and many previously inactive patients participated in sports after THA [405]. These data suggest that increased travel distance to treatment centers does not impact outcomes following primary THA [229].

Key Evidence¶

[L4] Total hip arthroplasty in patients under age 21 years yields substantial improvements in 5-year functional outcomes, regardless of etiology, with extremely low revision rates and excellent implant survivorship. [3] (10.1016/j.arth.2025.03.017)
[L5] The decision to perform revision hip arthroplasty of a metal-on-metal implant is multifactorial and should be based on documented, objective clinical indications. [4] (10.5435/jaaos-d-14-00183)
[L4] The new classification system could help surgeons estimate potential difficulties during total hip arthroplasty. [10] (10.1186/s12891-020-03678-4)
[L4] Hip arthroscopy may be useful in the diagnosis and treatment of apparently well-implanted but unstable total hip replacement prostheses. [12] (10.1016/j.arthro.2009.11.013)
[L4] At a population level, the lifetime risk of revision hip replacement remains low at <1 in 50 people in 2017. [13] (10.2106/jbjs.20.01235)
[L4] National implant registers define the epidemiology of primary and revision surgery and, in conjunction with individual subjective patient data and radiography, contribute to the development of evidence-based THA surgery. [14] (10.1097/01.blo.0000193517.19556.e4)
[L5] This article highlights common causes of early revision total hip arthroplasty and provides specific technical strategies to avoid complications. [17] (10.5435/jaaosglobal-d-22-00234)
[L3] The findings suggest that total hip arthroplasty in adolescents should be reserved for carefully selected patients for whom alternative procedures are contraindicated or unacceptable. [18] (10.2106/00004623-199607000-00003)
[L3] A clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy within 2 years. [19] (10.1186/s12891-019-2646-5)
[L4] This technology may help clinicians objectively define a diagnosis of impingement in total hip prostheses in the absence of other clinically identifiable sources of pain. [20] (10.5435/jaaos-d-25-01440)
[L5] [21] (10.1007/s11999-015-4341-7)
[L5] [22] (10.5435/00124635-200203000-00004)
[L5] Total hip arthroplasty is increasingly offered for the management of osteoarthritis of the hip in patients with fragile or pathologic bone, supported by early literature demonstrating improved functional and patient-reported outcome scores. [23] (10.2106/jbjs.20.01398)
[L3] In total hip arthroplasty, X-rays taken immediately after surgery rarely reveal unknown complications. [25] (10.1186/s42836-022-00148-1)
[L4] Focusing on primary THAs initially performed by a contemporary, subspecialty practice allowed an accurate determination of etiologies and rates of failure after THA. [26] (10.5435/jaaos-d-17-00842)
[L3] Adjustments for differences in age and prosthesis choice must be made when the results of hip arthroplasty are studied in different diagnostic groups. [27] (10.1016/j.arth.2007.03.023)
[L4] As clinical outcomes continue to be inferior to those of THA for osteoarthritis, larger multicentre studies are required to investigate possible differences between surgical indications and techniques. [28] (10.1302/0301-620x.107b8.bjj-2024-1232.r1)
[L3] These findings suggest that contemporary THA provides similar clinical benefits across both diagnoses. [30] (10.1016/j.arth.2026.06.023)
[L3] Almost one-third of adverse events following total hip arthroplasty were diagnosed between postoperative days 31 and 90, highlighting the importance of looking beyond 30 days when estimating patients' risk of postoperative adverse events. [32] (10.1016/j.arth.2022.10.020)
[L3] In the setting of severe symptoms and the absence of advanced OA on radiographs, advanced imaging can be used to guide treatment and select patients who could benefit from THA. [33] (10.1016/j.arth.2024.05.043)
[L2] Compared to osteoarthritis, a diagnosis of osteonecrosis was associated with worse outcomes post-THA. [34] (10.1186/s12891-016-1385-0)
[L3] THA remains an effective treatment for severe hip osteoarthritis, but females presented with worse baseline conditions and showed relatively less improvement at 1-year postsurgery compared to males. [35] (10.1002/ksa.12124)
[L3] [36] (10.1016/j.arth.2021.02.031)
[L1] However, total hip arthroplasty may be considered for younger and more active patients based on expert opinion. [38] (10.1016/j.arth.2024.10.085)
[L4] Nonetheless, total hip arthroplasty proved to be reliable for alleviating pain and improving function in patients with advanced symptomatic arthritis of the hip secondary to osteochondrodysplasia. [39] (10.2106/00004623-200402000-00012)
[L3] These results support the reclassification of conversion into a diagnosis-related group separate from primary THA. [40] (10.1016/j.arth.2020.12.023)
[L3] Because of their reported higher risks, there is no clear indication for modularity with a primary THA, unless the hip center cannot be achieved with a nonmodular stem. [41] (10.1007/s11999-013-3361-4)
[L4] However, due to potential for subsequent need for THA in a subset of this population, surgeons should use rigorous selection criteria and counsel patients appropriately. [42] (10.1016/j.arthro.2018.05.034)
[L1] The incidence in worldwide arthroplasty register datasets is 304 fractures per 100,000 implants, meaning one out of 323 patients undergoes revision surgery due to an implant fracture after THA in their lifetime. [43] (10.1007/s00264-013-2110-3)
[L5] Despite increased risks for both medical and surgical complications, total hip arthroplasty in the appropriately selected patient can provide significant pain relief, restoration of function, and patient satisfaction. [44] (10.5435/00124635-200505000-00007)
[L4] Total hip arthroplasty performed in young and presumed active patients younger than 65 years has excellent survivorship at the mid-term follow-up. [47] (10.5435/jaaosglobal-d-22-00256)
[L3] Implant survivorship at 2, 5, and 10 years is among the best reported for any total hip system in the world. [48] (10.1016/j.arth.2020.01.063)
[L4] Sixty-nine percent of the original hip replacements were functioning well at the latest follow-up examination or at the time of death, and only 5% required more than one revision arthroplasty. [50] (10.2106/00004623-200306000-00013)
[L3] Patients reported higher rates of worsening and lower rates of improvement following revision total hip arthroplasty than primary total hip arthroplasty, with significantly less score improvement and lower postoperative scores for all patient-reported outcome measures after revision. [51] (10.1016/j.arth.2023.05.053)
[L4] Nonagenarians undergoing primary THA had substantial mortality rates at 90 days (6%) and 1 year (8%). [53] (10.1016/j.arth.2020.10.040)
[L4] Survivorship for revision total hip arthroplasty using second revision as an endpoint was 82% at 10 years. [63] (10.1007/s11999-008-0566-z)
[L4] Primary THA in AS patients demonstrated favorable survival at 10 years but poor long-term survival. [64] (10.5435/jaaosglobal-d-25-00115)
[L5] Promoting one surgical approach over another is marketing without substantial proof of superiority; surgical technique, clinical experience, and modern-day pathways play the most substantial roles in providing excellent care during total hip arthroplasty. [66] (10.2106/jbjs.21.01047)
[L5] Total hip arthroplasty for developmental dysplasia of the hip is a technically demanding surgery requiring an in-depth understanding of anatomical abnormalities and complex techniques. [69] (10.1186/s42836-019-0004-6)
[L3] Patients who received primary total hip arthroplasty via the direct anterior approach were more likely to receive revision total hip arthroplasty via a discordant approach compared to other primary approaches. [70] (10.1016/j.arth.2023.06.040)
[L5] All three surgical approaches (posterior, direct lateral, and direct anterior) are safe and have excellent results in patients undergoing primary total hip arthroplasty. [72] (10.1016/j.arth.2024.10.036)
[L4] Revision total hip arthroplasty through the direct anterior approach is technically challenging but offers advantages in exposure of the acetabulum and can yield generally good postoperative function. [73] (10.2106/jbjs.j.01736)
[L5] The diagnosis of infection following total hip arthroplasty relies on the surgeon's judgment of the clinical presentation, physical examination findings, and interpretation of previous investigations, as no single test is 100 percent sensitive and specific. [75] (10.2106/00004623-199710000-00015)
[L5] Minimally invasive total hip arthroplasty is a safe procedure in skilled hands that does not increase complication rates compared to traditional approaches, with short-term results being the same as long incisions. [76] (10.1097/blo.0b013e3181468766)
[L1] Osteonecrosis itself, or when associated with the most common risk factors and/or diagnoses, is not associated with poor outcomes in total hip arthroplasty. [77] (10.1007/s00264-010-0979-7)
[L5] Evaluation of the painful hip after total hip replacement requires a careful elicitation of the patient's history and examination to distinguish between intrinsic and extrinsic sources of pain. [79] (10.2106/jbjs.i.00362)
[L5] The direct anterior approach (DAA) may be comparable to other total hip arthroplasty approaches, but there is no evidence to date that shows improved long-term outcomes for patients. [80] (10.5435/jaaos-d-20-00334)
[L5] The two-incision total hip arthroplasty is a technically demanding procedure that requires careful patient selection, preoperative templating, and attention to details to avoid potential complications, but it offers the opportunity to obtain all the benefits of modern hip arthroplasty with the advantage of a shorter recovery and quicker rehabilitation. [82] (10.1097/01.blo.0000192361.00227.6f)
[L5] This modified approach preserves the benefits of the anterior approach while addressing practical limitations such as the need for a traction table and specialised equipment, offering a versatile, safe, and accessible option for primary and selected revision total hip arthroplasty. [84] (10.1186/s13018-025-06397-5)
[L1] [85] (10.1016/j.arth.2019.11.033)
[L2] There should be a low threshold to conduct a systematic clinical evaluation of patients with MoM hip arthroplasty as early recognition and diagnosis will allow the initiation of prompt and appropriate treatment. [88] (10.1007/s00264-016-3305-1)
[L4] Joint-preservation techniques should be utilized to facilitate future hip arthroplasty surgery. [90] (10.5435/jaaos-20-08-487)
[L1] Choice of surgical approach for THA should be based on patient factors, surgeon preference, and experience. [91] (10.1016/j.arth.2016.08.027)
[L3] [93] (10.1016/j.otsr.2018.01.006)
[L4] The authors believe that this operative technique of total hip arthroplasty is effective for the treatment of the difficult condition of high dislocation of the hip. [100] (10.2106/00004623-199804000-00007)
[L3] The ASI approach is a safe, minimally invasive method for performing primary total hip replacement that encourages early functional recovery. [102] (10.1302/0301-620x.96b11.34348)
[L4] The authors present a classification system and algorithmic approach to guide femoral reconstruction in revision total hip arthroplasty, recommending specific implant strategies based on the type of femoral deficiency to ensure stability and osseointegration. [105] (10.2106/00004623-200300004-00001)
[L5] Patients who present with or whose condition progresses to collapse of the femoral head will require treatment with a standard total hip arthroplasty. [106] (10.2106/jbjs.i.00345)
[L3] [107] (10.1016/j.injury.2024.111970)
[L1] [108] (10.2106/jbjs.21.01411)
[L3] Most patients who have had a right total hip arthroplasty have recovered sufficient hip function to return to driving 4 to 6 weeks postoperatively. [110] (10.1097/01.blo.0000072468.32680.ff)
[L5] A systematic approach to the failed THA is paramount to identifying the correct diagnosis and selecting the proper treatment. [111] (10.5435/jaaos-d-25-00823)
[L4] The paper details the history, physical examination, and diagnostic workup of extra-articular sources of pain after total hip arthroplasty, including iliopsoas impingement, greater trochanteric pain syndrome, and deep gluteal space pathology. [113] (10.5435/jaaosglobal-d-25-00226)
[L3] Although most periprosthetic fractures following THA are fragility fractures that qualify patients for osteoporosis diagnoses, there remain major gaps in diagnosis, screening, endocrinology follow-up, and treatment. [114] (10.1016/j.arth.2024.06.002)
[L5] [118] (10.1016/j.arth.2018.01.047)
[L2] Abnormal hip and knee joint loading during walking after THR has a biomechanical background originating from hip geometry reconstruction. [119] (10.1016/j.arth.2019.07.027)
[L4] The presence of cerebral palsy is not a contraindication for either hip arthrodesis or total hip replacement for a painful deformed or degenerated hip. [121] (10.2106/00004623-198668040-00017)
[L5] This review outlines management strategies for isolated greater trochanter fractures associated with total hip arthroplasty, proposing a new classification system based on fracture location relative to insertional anatomy to inform treatment recommendations for intraoperative, postoperative, primary, and revision settings. [122] (10.5435/jaaos-d-23-00560)
[L5] The differential diagnosis of persisting unusual symptoms after total hip replacement has to include a fistula between the total hip prosthesis and urinary tract, even in the absence of open sinuses. [123] (10.1007/bf00454733)
[L1] [125] (10.1186/1749-799x-3-31)
[L5] Impingement is a cause of poor outcomes of prosthetic hip arthroplasty; it can lead to instability, accelerated wear, and unexplained pain. [126] (10.2106/jbjs.f.01313)
[L3] Combinations of gait and joint positioning parameters together explained up to 86% of the variation in hip force parameters. [127] (10.1002/jor.20935)
[L4] Hip arthroscopy after hip arthroplasty is uncommon but occurs more frequently in female patients, is undertaken in a broad age range of patients, and often is associated with a diagnosis of iliopsoas or hip tendinitis. [128] (10.1016/j.asmr.2024.100987)
[L3] Gender factors, potentially hormonal, anatomic, or functional, influence the success of metal-on-metal THA, leading the authors to expand contraindications to avoid this device in female patients. [132] (10.1016/j.arth.2011.04.012)
[L3] Operative diagnosis is independently associated with ADL limitations, but not pain, at 2-years after revision THA. [133] (10.1186/1471-2474-14-210)
[L4] Among young THA patients, postoperative complication rates varied by indication; however, long-term implant survival is reassuring regardless of surgical indication—with 10-year survival at approximately 94% for all groups analyzed. [134] (10.5435/jaaosglobal-d-25-00042)
[L3] Patients who exhibited rapidly progressive osteoarthritis before undergoing total hip arthroplasty showed worse patient-reported outcomes compared with those who did not have rapid progression. [136] (10.1016/j.arth.2024.04.016)
[L2] There remains no clear indication which THA bearing couple is the most biocompatible, especially in young active patients. [137] (10.1302/0301-620x.97b9.34824)
[L3] THA is an effective form of treatment for hip conditions in children, with a higher than normal incidence of revision surgery. [138] (10.1302/0301-620x.107b5.bjj-2024-0964.r1)
[Case_report] Vascular injury during total hip replacement can present as an acute abdominal condition without pronounced local symptoms, leading to delayed treatment and fatal outcomes. [139] (10.2106/00004623-199310000-00020)
[L5] Early periprosthetic femoral fracture after total hip arthroplasty is not simply the same fracture occurring sooner but represents a distinct clinical phenotype defined by risks of recurrent fracture, repeated reoperation, and sustained morbidity. [140] (10.2106/jbjs.26.00128)
[L4] The review evaluates the incidence, pathogenesis, diagnosis, and treatment of trunnionosis in metal-on-polyethylene total hip arthroplasty, noting that the true incidence is likely underreported due to variable clinical presentations and unclear pathogenesis. [141] (10.1016/j.arth.2018.05.035)
[L3] We recommend all patients undergoing implantation since 2006 and those with bilateral MoM hips undergo regular investigation, regardless of symptoms. [143] (10.1302/0301-620x.99b5.bjj-2016-1232.r1)
[L5] Classification and Management' by Mnaymneh WA, which provides a classification system and management strategies for bone stock deficiency in total hip replacement. [145] (10.2106/00004623-199072020-00038)
[L4] This femoral component afforded durable fixation at ten to twelve years after primary total hip arthroplasty. [147] (10.2106/00004623-200401000-00014)
[L4] Current analysis revealed trends that degenerative hips experience more abnormal hip kinematics that leads to higher articulating surface forces and stresses within the acetabulum. [149] (10.1016/j.arth.2019.08.057)
[L5] This study provides an overview on the characteristics and variations of modular hip taper connections and presents a new classification system regarding the surface finish. [150] (10.1016/j.arth.2017.04.027)
[Paper] The majority of patients undergoing total hip replacement can expect to return to work and sporting activities within 4-6 months. [151] (10.1007/s00402-013-1700-2)
[L4] The authors suggest a classification system for the length of femoral stems to better organize the discussion on stem length. [153] (10.1302/0301-620x.96b4.33036)
[L4] The score predicts surgical difficulties by adding criteria to bone destruction, in contrast to widely used classifications for revision THA. [154] (10.1016/j.otsr.2024.103983)
[L3] Conversion total hip arthroplasty remains a safe and effective treatment choice, though surgeons should counsel patients that it may take approximately 3 months for the median patient to experience clinically relevant improvement compared to 1.6 months for pTHA. [155] (10.1016/j.arth.2025.04.075)
[L3] We believe this implant should not be used and patients who have had this form of total hip arthroplasty should be kept under regular review. [156] (10.1007/s00402-007-0557-7)
[L3] After implementation of the 'fast-track' rehabilitation protocol, the mean length of hospital stay for primary total hip arthroplasty decreased from 4.6 to 2.9 nights for unselected patients. [159] (10.1302/0301-620x.97b1.33886)
[L3] While all fixation techniques performed well at long-term follow-up, cemented fixation was associated with the lowest implant survival in all age groups, including in more elderly patients. [160] (10.1302/0301-620x.104b2.bjj-2021-1199.r1)
[L4] Disturbances in spinal and pelvic kinematics lead to abnormal hip function, which may contribute to complications following total hip arthroplasty (THA). [161] (10.1016/j.otsr.2023.103773)
[L3] Setting preoperative PROM thresholds for THA eligibility did not guarantee clinically successful outcomes. [162] (10.1016/j.arth.2022.09.004)
[L1] THA surgical approaches present distinct efficacy-safety profiles with varying probabilities of advantage. [163] (10.1186/s12891-026-09683-3)
[L2] The proposed BOSTI Hip classification provides a reproducible grading system for stratifying iatrogenic bone trauma and soft-tissue injury during THA. [164] (10.1302/0301-620x.106b9.bjj-2024-0529.r1)
[L4] Selective use of MRI could be invaluable in directing the care of patients after hip arthroplasty. [166] (10.1016/j.arth.2008.04.023)
[L4] There is insufficient evidence to conclusively support the hypothesis that a specific surgical approach or minimally invasive technique provides faster recovery and return to function after total hip arthroplasty, and long-term data do not exist to confirm implant longevity. [167] (10.2106/jbjs.i.00343)
[L1] The majority of patients return to work after THA, and some patients are able to start working after surgery. [172] (10.1186/s13018-023-03578-y)
[L3] Overall, THA remains a safe and viable treatment modality beyond the ninth decade of life. [173] (10.1016/j.arth.2020.03.026)
[L3] With the numbers available, prior hip arthroscopy does not appear to have an impact on the functional outcomes of a subsequent THA. [174] (10.1016/j.arth.2016.01.008)
[L4] The authors present a validated classification system for acetabular bone loss that guides treatment and prognosticates outcomes. [176] (10.1016/j.arth.2007.05.020)
[L3] For those that qualify after careful selection, outpatient THA might be a feasible alternative to the traditional inpatient THA. [178] (10.1016/j.arth.2019.10.059)
[L4] The results encouraged the continued use of cementless fixation in total hip arthroplasty. [181] (10.2106/00004623-200306000-00015)
[L3] A leg length inequality in the range of 1–20 mm does not impair the symmetry of time–distance parameters and hip kinematics and kinetics during gait and stairs walking. [183] (10.1007/s00264-009-0855-5)
[L3] Hip offset differences greater or less than 5 mm do not significantly change gait patterns, and surgical approach plays a greater role than hip offset reconstruction in producing more normal gait biomechanics following total hip arthroplasty. [185] (10.1016/j.arth.2023.08.040)
[L3] Fifty-nine percent of patients returned to some form of recreational activity after total hip arthroplasty. [187] (10.5435/jaaosglobal-d-21-00160)
[L3] Total hip arthroplasty has positive effects on work capacity in patients who return to work. [190] (10.1016/j.arth.2008.11.011)
[L4] Total hip arthroplasty is a safe and feasible option for these complex injuries that carry poor surgical fixation outcomes. [192] (10.1016/j.injury.2025.112753)
[L3] In patients older than 65 years of age undergoing primary THA, cemented femoral fixation resulted in the lowest incidence rate of early PPF. [197] (10.1016/j.arth.2023.10.020)
[L5] Magnetic resonance imaging can be used to directly evaluate the integrity of metallic components and detect occult fractures of the femoral component after total hip arthroplasty, even when plain radiographs are normal. [199] (10.2106/00004623-200401000-00024)
[L2] Preoperative spinopelvic characteristics that contribute to abnormal mechanics can normalize after THA following improvement in hip flexion. [200] (10.2106/jbjs.21.01127)
[L3] Hip arthroplasty allowed regular and competitive golfers to return to the course with better golfing comfort than before surgery and with an objective improvement in driving distance and level of play. [203] (10.1016/j.arth.2021.04.004)
[L3] The study utilized data from the Swedish Hip Arthroplasty Register to evaluate the predictive ability of the ASA physical status classification system on health-related quality of life using eight EQ-5D-3L value sets across preoperative and postoperative periods up to 6 years. [205] (10.1186/s12891-020-03399-8)
[L5] The interplay between the hip and spine is one of the single timeliest topics in the field of hip arthroplasty, dependent on spinal stiffness, pelvic tilt, and dynamic hip positions. [206] (10.1016/j.arth.2018.12.035)
[L4] The study suggests primary total hip replacement may be the management of choice in rheumatoid patients and for young patients unsuitable for internal fixation. [207] (10.1016/0020-1383(81)90249-7)
[L4] The Unified Classification System (UCS) for peri-prosthetic fractures of the pelvis and femur demonstrated substantial and 'almost perfect' inter- and intra-observer agreement for both experts and pre-experts. [208] (10.1302/0301-620x.96b11.34214)
[L1] Uncemented and antibiotic-loaded cemented fixations remain options for the prevention of prosthetic joint infection in primary total hip replacement. [211] (10.3390/jcm8050722)
[L2] Kinematic pelvic changes highly impact cup anteversion in total hip arthroplasty. [213] (10.1002/jor.25106)
[L5] Postoperative physical therapy remains an essential component of standard care following total joint arthroplasty, but the specific approach should be individualized. [214] (10.1016/j.arth.2024.10.105)
[Paper] Superior displacement of the hip center caused a 13% decrease in the moment arm of the abductors and a 43% decrease in their force-generating capacity. [215] (10.1002/jor.1100140212)
[L4] Most patients are able to return to preoperative levels of low- and moderate-impact sports between 7 and 12 months after total hip arthroplasty. [218] (10.1177/03635465211045698)
[L5] Restoration of normal hip biomechanics, specifically limb length equality and offset, is a key goal of total hip arthroplasty that favorably affects functional recovery. [220] (10.1016/j.otsr.2015.11.001)
[L3] The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. [223] (10.1302/0301-620x.103b7.bjj-2020-2448.r2)
[L4] Most patients with a metal-on-metal total hip replacement who do not undergo early revision have normal MRI scans. [224] (10.1302/0301-620x.95b8.31377)
[L4] A rapid rehabilitation protocol is safe and fulfills the potential benefits of a rapid recovery with minimally invasive total hip arthroplasty. [225] (10.1097/01.blo.0000150127.80647.80)
[L3] The lumbosacral and hip motions were the major contributors to global alignment postural change. [227] (10.1186/s12891-021-04865-7)
[L4] These data suggest that increased travel distance to treatment centers does not impact outcomes following primary THA. [229] (10.1016/j.arth.2024.10.027)
[L4] Planning and measurement of the intended position of the acetabular component in the supine position may fail to predict clinically significant changes in its orientation during functional activities, as a consequence of individual pelvic kinematics. [232] (10.1302/0301-620x.99b2.bjj-2016-0098.r1)
[L4] The results of our model demonstrate that THA is a cost-effective option compared to non-operative management in patients 80 years old. [237] (10.1016/j.arth.2017.11.063)
[L3] These data suggest that rapid discharge following total hip arthroplasty can be performed safely in select patients older than 70. [239] (10.1016/j.arth.2023.08.065)
[L5] There is no benefit in hip range of movement or hip function when head sizes > 36 mm are used. [247] (10.1302/2058-5241.3.170061)
[L4] However, the authors note that a majority of Medicare patients will continue to require inpatient hospitalization during their immediate recovery after THA. [249] (10.1016/j.arth.2019.09.040)
[L1] In patients having unilateral total hip replacement, supervised and independent postdischarge rehabilitation did not differ for improving pain and function. [251] (10.2106/jbjs.18.00633)
[L3] Primary THA can be a reasonable treatment modality for patients failing nonoperative treatments given suboptimal outcomes with hip arthroscopy in the setting of early arthritis. [252] (10.1016/j.arth.2024.07.038)
[L1] The literature indicates a potential role for the hip joint capsule in mechanics via mechanoreceptors, though nomenclature is inconsistent and proprioceptive roles cannot be reliably confirmed as no study has reported type I-III mechanoreceptors. [253] (10.1371/journal.pone.0229128)
[L4] Total hip arthroplasty is unlikely to significantly deleteriously affect participation and performance in golf after an appropriate period of recovery, with patients having a good chance of returning to play approximately 6 months after operation. [255] (10.1016/j.arth.2006.05.030)
[L3] Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. [256] (10.1016/j.arth.2022.12.030)
[L3] After surgery, individuals with total hip arthroplasty displayed a persistent increased contralateral shift as compared to controls, indicating the need for rehabilitation focused on normalizing loading of the limbs. [259] (10.1186/s13018-020-01663-0)
[L3] The majority of patients report high levels of expectation fulfilment following THA at late follow-up. [261] (10.1007/s00402-020-03430-6)
[L4] At one year after primary THA, at least 13% of Danish patients experienced moderate to severe postsurgical pain. [264] (10.1016/j.arth.2025.09.057)
[L5] Functional improvement occurred after total hip arthroplasty among all studies, but obese patients generally did not attain the same level of physical function by the follow-up time point. [267] (10.1186/1749-799x-7-16)
[L4] Standard physiotherapy rehabilitation in the UK after total hip replacement is variable and appears to rarely include progressive resistance training (PRT). [268] (10.1186/1471-2474-14-91)
[L2] With modern surgical techniques and rehabilitation protocols, patients can, on average, return to safely braking a vehicle approximately 2 weeks after right total hip arthroplasty. [270] (10.5435/jaaosglobal-d-23-00093)
[L4] The combined imaging diagnostic criteria for aseptic loosening of the acetabular cup after total hip arthroplasty demonstrate superior diagnostic efficacy compared to single imaging parameters. [271] (10.1186/s12891-025-08607-x)
[L5] [273] (10.1097/01.blo.0000194727.55372.04)
[L1] We recommend such interventions to be combined with routine care soon after hip replacement. [276] (10.1186/s13018-022-03116-2)
[L1] This randomized trial suggests that unsupervised home exercise is both safe and efficacious for a majority of patients undergoing total hip arthroplasty, and formal physical therapy may not be required. [280] (10.2106/jbjs.16.00674)
[L4] Total hip replacement provided systematic alleviation of pain and did not aggravate functional status in non-ambulatory cerebral palsy patients, offering a more satisfactory outcome than proximal femoral resection despite a non-negligible rate of complications. [282] (10.1016/j.otsr.2016.07.010)
[L3] Both radiographic methods enable a simple orientation and a practical conventional radiographic estimation of stem torsion on hip radiographs after THA. [284] (10.1016/j.arth.2015.11.013)
[L5] Total hip replacement is an attractive solution for non-ambulatory patients with cerebral palsy to relieve pain, but the high complication rate (35%) and risk of revision require caution and a multidisciplinary team approach. [291] (10.1016/j.otsr.2017.02.002)
[L5] After THA, acetabular component position can be evaluated using a variety of imaging techniques. [292] (10.1016/j.arth.2026.09.026)
[L4] Primary total hip arthroplasty with the Taperloc femoral component in young patients was associated with a high rate of survival at 29 years. [299] (10.1016/j.arth.2015.12.026)
[L4] Primary total hip arthroplasty with the Taperloc femoral component is associated with a low rate of aseptic loosening at a mean follow-up of twenty years. [300] (10.2106/jbjs.g.00771)
[L3] MRI can effectively diagnose posterior capsular disruption in patients who have undergone THA via a posterior approach. [304] (10.5435/jaaos-d-18-00655)
[L4] [305] (10.1007/s00402-017-2741-8)
[L4] MRI can accurately describe ALTR in modular femoral neck total hip arthroplasty. [307] (10.1016/j.arth.2016.03.022)
[L5] Heterotopic ossification is a common radiographic finding after modern total hip arthroplasty, with prevalence ranging from 10% to 40% depending on the surgical approach. [314] (10.5435/jaaos-d-22-01070)
[L3] [316] (10.1007/s00264-014-2309-y)
[L1] [321] (10.1016/s0020-1383(00)00125-x)
[L4] [323] (10.1016/j.arth.2024.04.026)
[L4] [325] (10.1016/j.arth.2008.09.026)
[L3] Metal ion analysis should be used in conjunction with clinical and imaging evaluation and not as a sole indirect screening test when evaluating patients following metal-on-metal hip arthroplasty. [331] (10.2106/jbjs.l.01481)
[L4] [332] (10.1016/j.arth.2023.11.027)
[L4] [333] (10.2106/jbjs.j.00774)
[L3] Using digital radiography in conjunction with strict impingement testing allows for predictable cup placement in total hip arthroplasty, positioning the acetabular component within the desired target zone in 97.8% of cases. [334] (10.2106/jbjs.16.01501)
[L4] In this series of 309 primary THAs in patients with AS, the 20-year cumulative incidence of any revision after primary THA was 17.5%. [335] (10.1016/j.arth.2021.01.054)
[L5] Weight-bearing imaging is a critical adjunct to traditional supine radiographs for optimizing total hip arthroplasty component position to prevent instability and early wear. [336] (10.1055/s-0039-1697935)
[L4] [340] (10.1016/j.otsr.2009.03.011)
[L5] [344] (10.5435/jaaos-d-25-00476)
[L2] Patients awaiting THA and having combined high hip and reduced lumbar spine mobility can be screened for with lateral standing radiographs of the spinopelvic complex. [346] (10.1016/j.arth.2020.02.029)
[L4] The AI-based analyses can accurately and consistently evaluate postoperative THA radiographs. [348] (10.1016/j.arth.2026.07.013)
[L2] Plain radiography had the highest diagnostic accuracy in the evaluation of aseptic loosening of the acetabular component. [349] (10.2106/00004623-200411000-00015)
[L3] The long-term outcome of cemented primary and subsequent revision THA is promising in these young patients. [350] (10.1302/0301-620x.104b3.bjj-2021-0904.r1)
[L4] The cumulative incidence of periprosthetic femoral fracture after primary uncemented total hip arthroplasty further increased in the second decade and reached the incidence of aseptic stem loosening in the third decade, while no risk factors for the occurrence of a periprosthetic femoral fracture could be identified. [353] (10.1016/j.arth.2017.11.022)
[L5] The results indicate that this new method may function as an intraoperative alternative to DXA in THA, though more research and clinical trials are necessary before clinical use. [360] (10.1186/s13018-014-0109-0)
[L2] MARS-MRI is as suitable as standard diagnostic tools to distinguish between aseptic failure and PJI in patients with THA. [361] (10.1186/s12891-022-05560-x)
[L3] This study casts doubt on the significance of arthrographic evidence of loosening in the evaluation of the cause of pain after total hip replacement. [366] (10.2106/00004623-197557080-00004)
[L3] A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements. [371] (10.1186/1471-2474-15-168)
[L3] Contemporary aseptic revision THAs in patients ≤50 years of age demonstrated a re-revision risk of approximately 1 in 4 at 20 years. [372] (10.2106/jbjs.23.01467)
[L5] [377] (10.1007/s40883-021-00222-1)
[L4] [383] (10.1093/bmb/ldr011)
[L5] The incidence of secondary procedures did not differ significantly between patients, and total hip arthroplasty provided a statistically significant but clinically unimportant improvement in function and quality of life over 24 months. [384] (10.1302/0301-620x.102b6.bjj-2020-0101.r1)
[L4] Although 63% of the original hip replacements were functioning at the latest follow-up or at the time of death, a significant decrease in activity level was seen over time. [392] (10.2106/jbjs.m.01573)
[L3] While THA patients had more severe pain preoperatively, they experienced more immediate improvements in their pain outcomes, achieved an earlier plateau in their scores, and had lower postoperative pain than TKA patients. [395] (10.1016/j.arth.2026.04.109)
[L3] In postmenopausal women, HRT use before elective THA was associated with lower rates of periprosthetic fracture within 10 years of surgery and was not associated with increased venous thromboembolism risk. [401] (10.1016/j.arth.2024.12.020)
[L3] Most patients resumed or exceeded preoperative activity, and many previously inactive patients participated in sports after THA. [405] (10.1016/j.arth.2025.11.025)
[L3] There are greater incidences of periprosthetic joint infections and overall reoperations following early periprosthetic femur fractures compared to late fractures after total hip arthroplasty. [407] (10.1016/j.arth.2023.10.037)
[L4] At a minimum five-year follow-up, most patients who underwent DAA THA successfully returned to sporting activities, typically within six months postoperatively. [411] (10.1016/j.arth.2026.05.053)
[L4] These results support the conclusion that six months following surgery, the gait of the majority (85%) of THA patients has not returned to normal. [413] (10.1016/s0736-0266(03)00151-7)
[L3] Despite greater improvements on PROMs from preoperative to postoperative, patients undergoing early revisions after primary THA perceive significantly higher levels of pain and worse physical functionality at 1-year of follow-up. [419] (10.1016/j.arth.2023.07.019)
[L2] The integration of objective functional assessments in THA presents promise as a progress-tracking modality for improving patient outcomes. [422] (10.1302/0301-620x.106b8.bjj-2024-0142.r1)
[L3] Poor recovery following the first THA was highly predictive of second-side failure. [426] (10.1016/j.arth.2026.07.052)
[L1] The best evidence showed, with moderate certainty, that HA and THA likely result in similar revision rate, function, mortality, periprosthetic fracture, and dislocation at up to 5 years, with a small, possibly unimportant benefit in health-related quality of life with THA. [432] (10.2106/jbjs.20.00226)
[L3] Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup. [434] (10.1016/j.arth.2020.09.030)
[L4] However, variable functional recovery and a relatively high complication rate, particularly with tapered stems, warrant caution, and surgeons should set realistic expectations, as not all patients achieve optimal results. [435] (10.1016/j.arth.2025.11.012)
[L3] Patients who had prior lumbar spine surgery who underwent primary THA demonstrated equivalent improvements in PROs, but achieved lower overall postoperative scores and met hip arthroplasty thresholds at lower rates. [436] (10.1016/j.arth.2024.10.008)
[L3] Our results suggest that maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA. [437] (10.1186/s12891-020-3093-z)
[L3] Patients who had hip dysplasia and mild OA had similar recovery curves compared to those who had severe OA or who did not have dysplasia. [438] (10.1016/j.arth.2024.04.060)
[L1] Short-term recovery favors limited incision over standard incision THA. [440] (10.1007/s11999-012-2717-5)

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Total hip replacement

Overview¶

Anatomy & Pathophysiology¶

Surgical Approaches and Anatomical Landmarks¶

Biomechanics and Component Positioning¶

Pathophysiology of Complications¶

Classification¶

Periprosthetic Fractures¶

Bone Stock and Deficiency¶

Implant and Component Design¶

Preoperative and Patient-Specific Factors¶

Complications and Outcomes Reporting¶

Clinical Presentation¶

Indications and Patient Selection¶

Contraindications¶

Evaluation of the Painful Hip¶

Imaging and Diagnostic Modalities¶

Laboratory Assessment¶

Metal-on-Metal and Adverse Local Tissue Reactions¶

Periprosthetic Fractures¶

Revision Indications¶

Postoperative Monitoring and Adverse Events¶

Investigations¶

History and Physical Examination¶

Plain Radiography¶

Advanced Imaging¶

Laboratory Assessment¶

Other Considerations¶

Treatment¶

Non-Operative¶

Operative¶

Complications¶

Recovery¶

Key Evidence¶

See Also¶

References¶